Vesico-urethral anastomotic stenosis following radical prostatectomy: a multi-institutional outcome analysis with a focus on endoscopic approach, surgical sequence, and the impact of radiation therapy.

OBJECTIVES: To investigate the predictors of recurrence and of de novo incontinence in patients treated by transurethral incision or resection for vesico-urethral anastomotic stenosis (VUAS) after radical prostatectomy. MATERIAL AND METHODS: All patients undergoing endoscopic treatment for VUAS between March 2009 and October 2016 were identified in our multi-institutional database. Digital chart reviews were performed and patients contacted for follow-up. Recurrence was defined as any need for further instrumentation or surgery, and de-novo-incontinence as patient-reported outcome. RESULTS: Of 103 patients undergoing endoscopic VUAS treatment, 67 (65%) underwent transurethral resection (TR) and 36 (35%) transurethral incision (TI). TI was performed more frequently as primary treatment compared to TR (58% vs. 37%; p = 0.041). Primary and repeated treatment was performed in 46 (45%) and 57 patients (55%), respectively. Overall, 38 patients (37%) had a history of radiation therapy. There was no difference in time to recurrence for primary vs repeat VUAS treatment, previous vs no radiation, TR compared to TI (all p > 0.08). Regarding treatment success, no difference was found for primary vs. repeat VUAS treatment (50% vs. 37%), previous radiation vs. no radiation (42% vs. 43%), and TR vs. TI (37% vs. 53%; all p ≥ 0.1). Postoperative de novo incontinence was more common after TI vs. TR (31% vs. 12%; p = 0.032), no difference was observed for previous radiation therapy vs. no radiation therapy (18% vs. 18%; p > 0.9) or primary vs. repeat VUAS treatment (22% vs. 16%; p = 0.5). CONCLUSION: VUAS recurrence after endoscopic treatment is not predictable. Endoscopic treatment with TI showed a higher risk for de novo incontinence than TR, and previous irradiation and the number of treatments do not influence incontinence.

Influence of symptomatic pseudoaneurysms on postoperative renal function after partial nephrectomy: results of a matched pair analysis.

PURPOSE: A symptomatic pseudoaneurysm (SPA) is a rare but severe complication after partial nephrectomy (PN). Selective trans-arterial embolization (TAE) is the treatment of choice with high success rates. However, the influence of this intervention on postsurgical renal function has not been studied. METHODS: Between 2005 and 2016 we performed 1047 PNs at our institution. Postsurgical SPA occurred in 40 patients (3.8%). Patients with and without SPA were matched in a 1:2 ratio concerning tumor complexity (RENAL) and pre-operative renal function (CKD stage). Any CKD upstage and a relevant CKD progression (CKD ≥ III) were defined as endpoints. Furthermore, the influence of the amount of contrast agent applied during TAE was assessed. RESULTS: All patients with SPA were treated successfully with TAE. No significant difference could be detected concerning clinical, functional and surgical aspects. Median follow-up time accounted for 12.5 (6.75-27.5) months. Kaplan-Meier analyses detected an increased rate of any CKD upstage (p = 0.066) and relevant CKD progression (p = 0.01) in patients with SPA. Multivariate analysis identified post-operative SPA to be an independent predictor for a relevant CKD progression (HR 4.15, p = 0.01). The amount of contrast agents used did not have an impact on the development of a relevant CKD progression (p = 0.72). CONCLUSION: Patients treated with TAE after PN show an additional risk for an impairment of renal function over time. Hence, those patients should explicitly be informed about possible consequences and closely monitored by nephrologists.

Novel insights into a reputably irreversible process: combined mRNA and miRNA profiling of tissue from vesicourethral anastomotic stenosis after radical prostatectomy.

PURPOSE: Until recently, tissue fibrosis-ultimately leading to permanent scaring-has been considered an irreversible process. However, recent findings indicate that it may be reversible after all. Vesicourethral anastomotic stenosis (VUAS) as fibrous narrowing is a frequent complication after radical prostatectomy with high recurrence rates and requires invasive treatment. The pathophysiology is poorly understood. Therefore, a combined mRNA and miRNA transcription profiling in tissue from VUAS was performed using nCounter technology. METHODS: To assess tissue morphology and fiber composition, histochemical staining was performed. RNA expression of healthy and fibrotic tissue of twelve patients was analyzed using the human miRNA panel v3 and mRNA PanCancer pathway panel on the nCounter gene1 system and qRT-PCR. Differential expression data analysis was performed using the nSolver software implementing the R-based advanced pathway analysis tool. miRWalk2.0 was used for miRNA target prediction. RESULTS: More linearized tissue architecture, increased collagens, and decreased elastic fibers were observed in VUAS samples. 23 miRNAs and 118 protein coding genes were differentially expressed (p < 0.01) in fibrotic tissue. miRNA target prediction and overlap analysis indicated an interaction of the strongest deregulated miRNAs with 29 deregulated mRNAs. Pathway analysis revealed alterations in DNA repair, cell cycle regulation, and TGF-beta signaling. qRT-PCR confirmed differential expression of top deregulated miRNAs and mRNAs. CONCLUSIONS: In VUAS tissue, severe alterations on mRNA and miRNA level are found. These consistent changes give insights into the pathogenesis of VUAS after radical prostatectomy and point to future options for transcriptomics-based risk stratification and targeted therapies.

Zonal NephRo Score: external validation for predicting complications after open partial nephrectomy.

PURPOSE: The aim of the study was to externally validate the Zonal NePhRO Score (ZNS) published in 2014 as latest and superior nephrometry score in terms of prediction of perioperative complications and outcome of open partial nephrectomies (OPNs). METHODS: We identified 200 consecutive patients who underwent OPN. Analysis of preoperative CT or MRI scans and retrospective analysis of the patients' clinical records were performed. Tumour complexity was stratified according to the ZNS into three categories: low (4-6), moderate (7-9) and high (10-12) complexity. Predictors for perioperative complications and surgical parameters were identified using univariate and multivariate logistic regression. RESULTS: Tumour complexity was graded in 19.8 % of the cases as low, in 50.3 % as moderate and in 29.9 % as high. In the multivariate analysis, ZNS was significantly associated with a higher complication rate (OR 1.25, 95 % CI 1.04-1.49, p = 0.014), longer ischaemia time (IT) (ß = 1.19, 95 % CI 0.33-2.05, p = 0.007), postoperative drop of estimated glomerular filtration rate (eGFR) (ß = -1.86, 95 % CI -3.71 to -0.01, p = 0.049) and opening of the collecting system (CS) (OR 1.72, 95 % CI 1.40-2.10, p < 0.001). In addition, age and body mass index were identified as independent predictors for complications (OR 1.03, 95 % CI 1.00-1.06, p = 0.043 and OR 1.08, 95 % CI 1.00-1.15, p = 0.031). CONCLUSION: The present study is the first external validation of the ZNS as a predictor of perioperative complications in patients undergoing OPN. A higher ZNS score was associated with a longer IT, a higher rate of opening the CS and drop of eGFR.

Transurethral versus suprapubic catheter at robot-assisted radical prostatectomy: a prospective randomized trial with 1-year follow-up.

OBJECTIVE: To evaluate urethral catheter (UC) versus suprapubic tube (SPT) without stenting the anastomosis at robot-assisted radical prostatectomy (RALP) regarding surgical outcome and catheter-associated discomfort. One year after surgery, continence and patient satisfaction were evaluated. MATERIALS AND METHODS: Sixty-two patients undergoing RALP were prospectively randomized to urinary drainage with UC or with SPT. Functional results were assessed with standardized questionnaires (IPSS, IPSS Bother Score, IIEF and Visual Analogue Scale) preoperatively, after catheter removal and 1 year after surgery. Moreover, bother by the catheter as well as pain due to the catheter was assessed. RESULTS: At personal hygiene, SPT was significantly less bothersome on the day of surgery as well as POD 1-6. Pain caused by the catheter did not differ significantly between the two groups except for POD 5 and 6, when the SPT performed significantly better. Differences regarding voiding parameters after catheter removal did not reach statistical significance. One year after surgery, no significant difference between the two groups was found regarding urinary function and IPSS. Though not statistically significant either, the need for the incision of bladder neck contracture (BNC) in two patients in the UC group is of note, as in the SPT group, no BNC occurred. CONCLUSION: Draining the bladder with SPT only is a feasible option in patients undergoing RALP. Patients with SPT are significantly less bothered by the catheter at personal and genital hygiene compared to UC. The risk of BNC seems to be reduced in the SPT group.

Open Partial Nephrectomy for High-Risk Renal Masses Is Associated with Renal Pseudoaneurysms: Assessment of a Severe Procedure-Related Complication.

OBJECTIVES: A symptomatic renal pseudoaneurysm (RPA) is a severe complication after open partial nephrectomy (OPN). The aim of our study was to assess incidence and risk factors for RPA formation. Furthermore, we present our management strategy. PATIENTS AND METHODS: Clinical records of consecutive patients undergoing OPN were assessed for surgical outcome and postoperative complications. Renal masses were risk stratified for tumor complexity according to the PADUA score. Uni- and multivariate analysis for symptomatic RPAs were performed using the t-tests and logistic regression. RESULTS: We identified 233 patients treated with OPN. Symptomatic RPAs were observed in 13 (5.6%) patients, on average 14 (4-42) days after surgery. Uni- and multivariate analysis identified tumor complexity to be an independent predictor for symptomatic RPAs (p = 0.004). There was a significant correlation between RPAs and transfusion and the duration of stay (p < 0.001 and p = 0.021). Symptomatic RPAs were diagnosed with CT scans and successfully treated with arterial embolization. DISCUSSION: Symptomatic RPAs are not uncommon after OPN for high-risk renal masses. A high nephrometry score is a predictor for this severe complication and may enable a risk-stratified followup. RPAs can successfully be located by CT angiography, which enables targeted angiographic treatment.

[Sachse internal urethrotomy: endoscopic treatment of urethral strictures]. / Die Sachse-Urethrotomie: Endoskopische Behandlung von Harnröhrenstrikturen.

The most commonly used treatment modality for urethral strictures is the direct visual internal urethrotomy (DVUI) method according to Sachse. It is an effective short-term treatment, but the long-term success rate is low. A number of factors influence the outcome of DVUI including stricture location, spongiofibrosis and previous endoscopic stricture treatment. Multiple urethrotomy has a negative impact on the success rate of subsequent urethroplasty. A thorough preoperative diagnostic work-up including combined retrograde urethrogram/voiding cystourethrogram (RUG/VCUG) and urethrocystoscopy is, therefore, mandatory to allow for patient counselling regarding the risk of stricture recurrence and other treatment options. After a failed primary DVUI, subsequent urethrotomy cannot be expected to be curative.

Two-staged urethroplasty: buccal mucosa and mesh graft techniques.

PURPOSE: The purpose of this study was to describe indications, the operative technique and results of the two-staged buccal mucosa (BM) and mesh graft urethroplasty for treatment of urethral strictures. MATERIAL AND METHODS: Between 3/1993 and 12/1999, urethral reconstructions were performed in 267 consecutive patients (group I), including 68 mesh graft urethroplasties (25 %) and 30 BM urethroplasties (12 %). Between 1/2000 and 8/2004, additional 249 urethroplasties were performed: Of those, 12% were mesh graft and 50% BM urethroplasties (group II). RESULTS: In patient group I, stricture recurrence was found to be the main complication of both procedures (BM 17 %, mesh 16 %). However, erectile dysfunction and curvature only occurred in the mesh graft group with 4% and 9 %, respectively. Patient satisfaction was high in both groups (BM 96.7%, mesh 83.3%). Between 1/2000 and 8/2004 (group II) the number of BM urethroplasties increased to 50%, whereas the number of mesh graft urethroplasty decreased (12%). More than 80% of the patients were satisfied with the results. CONCLUSIONS: Long strictures with severe spongiofibrosis represent an indication for two staged urethro-plasty (BM and mesh graft). Excellent results can be achieved with both techniques with a similar rate of complications. The mesh graft technique remains the last option for a complex patient group.